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Part 1: The Dutch and English Societies, origins
Part 2: Ventilation Continues
Part 3: Compressions
Part 4: Defibrillation
Part 5: Present Day and Popular Culture
Precordial Thump digression
Outline and Notes Holding
References
Dr. Aaron Silver Fox Doc
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This episode isn’t just an excuse for me to talk about some wrestling history–it is definitely that though. It’s also to talk about a unique medical condition in how it affected a special person in the world of wrestling. We’ll start by talking about Andre The Giant, one wrestler that many non-fans of the sport have probably heard of, and then we’ll pivot to talking about the medical condition that made him so famous. I promise I won’t go too far into the wrestling side of this story so Mike doesn’t leave, but we have to talk about a bit of it because it’s awesome. Andre Rene’ Roussimoff grew to be every bit the giant of his namesake, both in physical stature and his career in the world of professional wrestling, which some might argue is the pinnacle of performance art and human achievement. I would argue that it is. After his initial training as a wrestler in France where, again he was an 18 year old, 7+ foot teenager who could just lift cars, mind you, he eventually made his way over to the U.S. where he wrestled in various regional wrestling territories as a true spectacle. He would come to town, beat everyone while crowds stood in awe of his size and ability to pick up and throw his opponents whether or not they wanted him to. Then he’d move on to the next town and the next wrestling territory. It was important not to keep him in town forever since nobody who saw him would ever believe he would lose a match. That’s also why he rarely if ever won championship belts. In 1973, he captured the attention of Vince McMahon Sr. who brought him into what was known as the WWF at that time. Note this was the father of the Vince McMahon who presently oversees the WWE and is known to not only be a ruthless businessman, but also to be a person who should not have a mustache–gotta be aware of recent wrestling to appreciate that one, but I know someone out there will. It makes him look every bit as unsettling as his history in the wrestling business would suggest he is. During his career, Andre was billed as being 7’4” and up to 555lbs. It may shock you to know that there may be some exaggeration in wrestling when it comes to these things, but it’s probably only a little bit over the mark for Andre’s true size. He was called the 8th Wonder of the World and indeed did wrestle all over the world. His biggest match, perhaps, was at Wrestlemania III in 1987, when I was all of 5 years old, Walk Like an Egyptian by the Bangles was #1 on the Billboard charts, and Aaron and Mike were celebrating their graduation from medical school, to give everyone historical context. Andre allowed Hulk Hogan to bodyslam him and was pinned in front of 78,000 fans–arguably the pinnacle moment for 1980’s wrestling. I did say he “allowed” Hogan to do so because, given his size, if Andre didn’t want to lose, he wouldn’t. I encourage everyone to check out the excellent HBO documentary on Andre the Giant to hear anecdotes about the times Andre didn’t like the wrestlers he was pitted against and used his size to make their time in the ring together difficult. And lastly, if you didn’t know him for the wrestling, you probably saw him in several movies. He was the star of the 1987 hit, The Princess Bride, where he played Fezzik who was, also a giant. I don’t know who else was in that movie because it had Andre the Giant in it and that’s by far the coolest thing about the movie. At this point, I hate to turn away from talking about wrestling, but there is a medical history part of all of this. Now that we know a bit about the man’s wrestling career, let’s talk about the underlying condition that made him 7+ feet tall, aptly named gigantism, and how it was discovered. I’ll note here that this condition may be referred to as acromegaly and I’ll be sure to tell you the difference between the two after we get to what causes them. For now I’ll use them interchangeably, but there is a difference. The first time a physician described gigantism was in the 16th century. It wasn’t the first case ever, of course, just the first time a physician took the time to write a scientific–if not rude and unkind–account of a patient having it. There is little to no tact in historic medical writings. Johannes Wier (pronunciation?) was a Dutch physician who in 1567 wrote about what he dubbed a “female giant.” She was 25 years old and had been making a living as a traveling sideshow performer to support her parents. Her stature was the show. She had apparently been normal in appearance until her early teens when her height, facial, and extremity size had all increased markedly. I mentioned his description was unkind and include it as an example of how harsh earlier medical journal observations could be, “her form was not attractive, her temperament was simple and stupid, and her whole body was sluggish.” If I could say anything redeeming about Dr. Weir’s writing, it’s that he would go on to write a bunch of treatises on why burning women for witchcraft was dumb and cruel and he apparently may have been among the first to use the term “mentally-ill” to describe women accused of witchcraft as opposed to saying they were, you know, “a witch.” So I guess that’s kind of progressive for the 16th century, maybe? Many cases of similar patients with similar findings–large extremities (especially hands, feet, heads/faces and tall stature) would be described over the subsequent centuries–interestingly enough often in France and the UK and Ireland it so happens. The first time the term “acromegaly” was used to describe this was in 1886 by French neurologist, Pierre Marie. Pierre was covering for his buddy, a physician named Jean-Martin Charcot who was a big fan of things that come in threes. Pierre Marie was seeing a few of his Charcot’s patients in late 19th century Paris–not clear if they were referred to him or he was, like, taking call for the clinic or something. One woman, aged 24, stopped in after her relatives noted a significant change in her appearance. Not sure why or what she was doing, but she was away from her family for a few years and when she’d returned many of them could not recognize her, due to the change in her appearance. Her face had grown, her arms, legs, and hands were quite large, and she, to Dr. Pierre Marie’s surprise, did not resemble old photos of herself. He dubbed the condition “acromegaly” which refers to extremities (akron - tip) and large (megas). Incidentally, she was having some difficulties with her vision which is a clue to what causes this condition. Let’s go there next. Ever since Dr. Wier’s initial description, on through the centuries leading up to Dr. Marie’s coining of the term, many physicians were aware of patients with enormous extremities and general size, and some of them were finding a curious association when they decided to open them up–post mortem, of course. We’ll start with a missed opportunity to make an eponym. A historically famous Scottish surgeon of the 18th century, John Hunter, came close to being the first to find a clue. He’s like the Drew MacIntyre of the world of surgical history, just for reference. He had procured the body of a man named Charles Byrne (aka Patrick O’Brien–I did not dive into why he had such different names) who was 7’7” and therefore known as “The Irish Giant”. Hunter loved collecting specimens like other people collect baseball cards or pokemon. He was able to keep Byrne’s enormous skeleton for his collection but he never opened it up. My wife would not have that problem since, whenever she gets a new wrestling action figure as a present, opens the package and immediately nosedives its value. Fast forward to an Italian neuropsychologist named Andrea Verga who did open up his patient up during his career in the 19th century. He was working at an Italian hospital in the 1860’s when he noted a woman (I think she was a patient) who had what he called “prosopo-ectasia” or big face. He was also not kind in describing her features as you might imagine. She died a few years later in 1862 of infectious illness and he did an autopsy–I don’t know that she was a longer term patient of his or if you could call a weird sort of dibs on patients bodies or however he was able to do this–but he found a “walnut sized” tumor in the region of her pituitary gland. Notably, he did not find a normal pituitary gland. That patient was also having vision difficulties when she was alive because, anatomically, the pituitary gland sits near near a big ol’ crossing of vision nerves called the optic chiasm, which carry signals from your eyes to the brain. Tumors of the pituitary can grow to push on the chiasm and cause vision changes. Many, many autopsies on patients with acromegaly or gigantism were performed, all of which seemed to have abnormal growths on the pituitary gland. In fact, one Lithuanian endocrinologist-diabetologist (redundant specialty name) named Oskar Minkowski noted in 1887–the year after Acromegaly was named–that all patients with the condition had these pituitary tumors on autopsy. That same year, an Italian physician named Vicenzo Brigidi did an autopsy of the brain of the Italian actor Ghirlenzoni (single name, like Cher?). He had acromegaly. Birgidi put was the first to look at the tissue under a microscope. Subsequent physicians found further evidence, microscopically, that the cells of the pituitary seemed to be really, really active. At this point the physicians of the late 19th century were pretty sure the pituitary tumors were causing acromegaly/gigantism. They were right. Here’s what’s happening with this condition. In 95% of cases, a non-cancerous tumor grows in the part of the pituitary gland that makes something called “growth hormone.” It’s nice when medicine names things for what they do. Growth hormone causes many tissues of the body, especially muscles and bones to grow, including those of the face and extremities. When you hear about athletes taking HGH (especially if they’re going up in hat sizes as the skull thickens), they’re injecting a synthetic form of this hormone to grow muscles. There are many other effects of GH but that’s beyond the scope of this show. So this is where the difference between gigantism and acromegaly comes into play. They are both due to excess production of growth hormone from the pituitary tumor. The difference is WHEN that production starts. If it starts before puberty–i.e. before most of the bones are done growing in length, then you have gigantism, which not only includes enormous growth of arms, legs, feet, and face, but significant height increase since the bones can grow longer as well. In acromegaly, the growth hormone excess starts AFTER puberty, when bones no longer grow in length, but can, with extra growth hormone, grow thick and distorted. Both conditions can affect the shape of the face in slightly different ways because of this. Also important to know that soft tissues like the tongue or soft tissues (the meat, if you will) of the extremities will grow as well. Acromegaly and Gigantism are fortunately treatable, to a degree. If recognized early, the first line is surgical removal of the tumor which stops the extra growth hormone from causing the changes. The earlier you catch it, the less the changes become permanent. Surgical treatment was an early recommendation after they figured out the pituitary tumor was the problem. In 1908, Austrian surgeon Julius Von Hochenegg performed the first trans-sphenoidal approach for treatment of acromegaly, earning a headline in the NY Times that year of “ACROMEGALY CURED.” Well, it wasn’t far off but it wasn’t until surgical microscopes became all the rage in mid 20th century that this surgery was refined and more often successful. There are now some medications that can be used if surgery is not an option or to temper the condition if surgery is not completely successful. Let’s finish out this story with the end of Andre’s life. Andre likely knew as early as the 1970’s that he’d had gigantism. According to one of his close friends, he had said that, on his initial wrestling trip to Japan–where he was an incredible wrestling star–he was told by a physician there that he likely had a pituitary tumor. It was not confirmed and there is speculation as to why he did not seek out surgery at that time. It might have been that there was a language barrier between Andre’s lack of French interpreter while in Japan, or that he may have known the option was there and decided against it. His friend said Andre was told he could have surgery while in Japan but that he said “God made him that way and he wasn’t going to change that.” In 1981, orthopedist, Dr. Harris Yett, diagnosed Andre with a broken ankle and being a giant human being. Prior to having the Giant undergo surgery and what I can only assume is an enormous dose of anesthesia, Yett had confirmatory testing done to, well, confirm, that Andre did have gigantism. Surgery on his pituitary was discussed but Andre declined because “he thought it would interfere with his career as a wrestler.” The sad thing, among many, is that if Andre had the surgery in 1981, he would have likely lived a longer life. His skeletal structure would not have changed, per se, but it’s likely the excess soft tissues may have shrunk and that he could have continued his wrestling career longer than he was able to. Andre really, really loved wrestling and what it gave to him and it seemed as if he accepted the fact that he would die young, but would live the life of a star in the meantime. If that trade off seems difficult to accept, consider how hard life was for Andre–and indeed others who have conditions of acromegaly and gigantism. He was comfortable being a Wonder of the World in the wrestling ring, but outside of it, he just wanted a normal life. He couldn’t use a bathroom on flights overseas. Clothing and furniture had to be custom made. People always tried to exploit him for his size and he knew that. So maybe that’s why he decided to forgo a treatment that would still, essentially leave him the way he was? By the late 1980’s, Andre’s career and health were on a precipitous decline. He had mounting back issues and could barely walk. His weight continued to grow as did the size of his heart. Andre died at age 46 of a suspected heart attack complicating congestive heart failure, on Jan 28th, 1993. He was alone in a Paris hotel room where he was traveling to attend his father’s funeral as sad as that is. You might imagine that Andre the Giant was not the only wrestler to have gigantism. Many before him did. One notable example is still wrestling today, albeit on a limited basis. Formerly known as “The Big Show” in WWE and “The Giant” in WCW before that, Paul Wight was diagnosed with his pituitary tumor in his late teens. He had it surgically removed and remained 7ft tall and between 383-500lbs at various points in his wrestling career. He’s 51 years old and active in wrestling to this day. I hope he’s a fan of this show! Hi Mr. Wight! Sources: https://karger.com/nen/article/103/1/7/220198/The-History-of-Acromegaly*** https://www.ncbi.nlm.nih.gov/books/NBK538261/ https://www.wwe.com/superstars/andrethegiant https://books.google.com/books?id=tYPCDwAAQBAJ&pg=PT78#v=onepage&q&f=false (suggestion that Andre may have been told of diagnosis in Japan in 1970’s) https://en.wikipedia.org/wiki/WrestleMania_III https://www.hbo.com/movies/andre-the-giant https://www.wrestlinginc.com/1097011/andre-the-giant-and-robin-wrights-relationship-on-the-princess-bride-explained/ https://biographics.org/andre-the-giant-biography-larger-than-life/ Dr. Max Doctor with a mustache. This case takes us to the mid 18th century to jolly ol’ England where a nervous 37 year old male awaits in the examination room to discuss what he feels is something of an embarrassing problem given the sensibilities of the time. He’s unkempt and filthy. He tells the surgeon that he’s noted a lesion on his “privvies” that started as a small bump or wart, perhaps, but now has grown into a 50-pence sized ulceration on the bottom of his scrotum, also medically known as the yambag. Anything you’d like to know about him at this point? The exam is concerning. There is an ulceration extending from the lower yambag with raised edges. No purulence, no infectious smell, mind you. You can’t see into the scrotum but the top tissue layers and underlying fascia seem to be visible. What would you want to do in modern times for this–let’s say in the ER. What about in the 1750’s? The surgeon treating this man will become known for associating this particular disease with the man’s profession. I’d wager that anyone having completed a stint in contemporary medical school will be aware of this surgeon’s name because it’s pasted all over the medical textbooks. This guy collects eponyms like I collect wrestling posters on my walls–fun fact, I have more wrestling pics on the walls of my office than degrees, I realized. Here’s the thing about this case. I didn’t write it quite accurately. The 37 year old patient I’ve made up is fictional. Though he is the average age of diagnosis of this condition at the time, the sad truth is it would be more likely that the patient we’re talking about with this life threatening disease would have been more likely to be a young boy, between the ages of 8 and young teens, likely. He’s filthy because it’s his job to be and that job is very likely to shorten his life, if not by this disease, then by another occupational or health-related hazard. Do you know what we’re talking about today? This is the story of the Chimney Sweep’s Carcinoma, diagnosed by the famous English surgeon, Dr. Percival Pott. This is a tale of occupational medicine at its earliest stages. The association of this cancer with the job of cleaning out chimneys was not accidental. The discovery of this led to sweeping (pun!) changes in social expectations for children and the labor market. Before we get to ol’ Percival Pott himself, let’s talk about what this patient–along with way too many children–would be diagnosed with. Chimney sweep’s carcinoma is really squamous cell carcinoma of the skin of the scrotum. Squamous cell carcinoma is a cancer that arises from the cells of the same name which can be found in your skin or the linings of one’s hollow organs, respiratory and digestive tube structures especially. As with any cancer, the basic problem is that a cell undergoes some sort of genetic change or damage and begins to grow and replicate without stopping. This results in a tumor or growth in many cases, but, with Squamous Cell carcinoma, the initial findings can appear to be an ulcer or wound which does not heal and slowly grows and expands, destroying more tissue around it. This type of cancer is nowadays rare in the “privies” so-to-speak, but very commonly found on skin. This disease would start insidiously for the unfortunate chimney sweeps, often as a mildly irritated sore or pimple-like bump. Might get some bleeding from scratching at it. It would start on the scrotum and, if not treated, the cancer would spread to the other areas of the genitals and, as it destroyed more tissue from the scrotum, would work its way into the testicle and on into the lymph nodes and structures inside the abdomen. Even in the modern era, from what I found, if you can resect–surgically remove–the cancer before it gets into the lymph nodes of the groin, chances are much better. We do chemo and radiation for this as well nowadays. If it makes its way into the inguinal nodes–those in the crease of your hip–there is a 25% 5 year survival rate. If it makes its way into the iliac nodes (deep within the pelvis) there is no survival reported beyond that time. That’s grim. But why were children in Dr. Pott’s heyday being diagnosed with this awful condition so often? Well, it was the beginning of the industrial revolution so that means progress in so many ways–except for those that involve treating children like human beings. You see, from the ages of 4 to prepuberty, the problem was that young boys were just too good at fitting in super dangerous small chimneys where they could do the insanely unsafe job of sweeping a flue for the betterment of society from the 1700’s to the 1800’s. Let’s talk about chimneys. A housing tax in 17th century England had limited the number of fireplaces allowed per house. This meant that houses and buildings were built with a labyrinth of chimneys and flues to get the smoke and soot from one’s fire up and out the top of everyone’s houses to create that soupy fog of carcinogens a person associates with images of London and most other metropolitan centers of the time. Seriously, smog was like a permanent season according to some accounts. Chimneys can collect soot and soot can be flammable if it builds up. Worse yet, if a chimney was plugged, one can imagine how bad that would be inside the house. This meant somehow, someone had to crawl up into the chimney to clean out the soot. That someone had to fit into places as narrow as 9”x9” in some flues so the natural conclusion was to “hire” young boys (again ages 5-11) to strip naked and shimmy their way into the twists and turns of the chimney. You might think the aristocracy of the day gladly offered up one or two of their extraneous progeny for the job, but you might be astonished to hear it was not their kids doing this work. Nope, it was often orphans, street kids, or children from poor families. They were paid badly and took so many risks. Boys might get caught in narrowed spaces and many died of suffocation. Sometimes, the chimneys were still hot or literally on fire from the prior uses. The soot would irritate their eyes to the point that some kids went blind from constant rubbing and scarring of the corneas. The soot also contributed to lung disease. The best case scenario for these kids was surviving to become a master chimney sweep, but that meant making money by exploiting the next generation of unfortunate souls. It was very unlikely for a chimney sweep to live to adulthood, let alone old age. When children would die on the job, the coroners of the time would classify these deaths as “accidental” as opposed to “occupational murder” which is what I’d call it. Speaking of soot–it’s bad. I mentioned the chimney sweep children were naked. This is because it made it easier to squeeze through the nooks and crannies of the passages but, believe it or not, this was part of the problem related to the cancer we are discussing. Soot would cover their bodies and especially collect in the area of the scrotum. Soot contains numerous carcinogenic substances and, with its prolonged contact with the skin, accompanied by the accepted unhygienic conditions of being a poor person in this time in the streets of London, there was high risk of developing cancer of the skin of the scrotum. Let’s return to our friend, the whimsically named Dr. Percival Pott, who lived between 1714 and 1788. He’s an English surgeon, credited with being the first to associate cancer with an occupation related environmental substance. He’s considered to be an occupational health pioneer. Dr. Pott did his surgical apprenticeship at St. Bartholomew’s Hospital over 7 years for a cost of 210 pounds (for all of it). In today’s money that is about $75k USD. He finished that apprenticeship and was hired by the Barbers’ Company, then being licensed to practice surgery. If it seems weird that barbers are licensing surgeons, I’ll refer you to our prior episode #40 to learn more about that whole matter. In 1744 he became an assistant surgeon at St. Bart’s and he went on to be a full fledged surgeon there from 1749 - 1787, the year before his death. I’m pretty sure his career at that one hospital was longer than the average lifespan of a chimney sweep, I’m sad to say. Interestingly, Dr. Pott was not quite the stereotypical surgeon one might expect of this time. He was known as a conservative-minded surgeon who was not quick to rush into a procedure. He was not a fan of “heroic medicine” which can generally refer to the gung-ho, “do something” attitude of the time. Bleed the patient, put leeches on them, make them vomit out the bad bile and amputate, amputate, amputate the problems away! Not for Dr. Pott. Here’s an illustrative example. In 1756, well into his surgical career, Pott was thrown from his horse, landing into the muck of the street, sustaining an open fracture to his tibia. That’s the type of break in the bone where the bone bits peek-a-boo through the skin to see what the outside world is all about. That’s a bad thing because the muck of the streets at this time was chock full of mud and horse manure rich with bacteria which, I should add, Dr. Pott and his colleagues of the time, didn’t even know caused disease. Bacteria and bones don’t mix particularly well and open fractures–especially in the age well before antibiotics, were frequently fatal infections waiting to happen. Pott was able to pay one of his servants to go to a nearby jobsite and buy a door. The door was used as a stretcher to return Dr. Pott home to await the opinions of his surgical colleagues of the time. To nobody’s surprise they voted to amputate his leg, and Dr. Pott was probably all like, “that sounds super fun but I’d rather not,” and he opted to conservatively treat the wound and fracture. This means they cleaned the hell out of it, splinted it, and, in time, Pott avoided dying of both 18th century surgery and infection, going on to a full recovery. So it wasn’t without reservation that he suggested surgery for patients and would be sure it was the only chance. In cases of scrotal cancer, the chimney sweep disease, he was right. If the cancer could be resected before it went to lymph nodes, patients would do well enough. If not, these poor souls would have an untimely end. Pott describes the circumstances of the Chimney Sweepers Carcinoma in, dare I say, empathetic terms especially given the time:: “The fate of these people seems peculiarly hard … they are treated with great brutality … they are thrust up narrow and sometimes hot chimneys [sic], where they are bruised, burned and almost suffocated; and when they get to puberty they become … liable to a most noisome, painful and fatal disease.” That’s downright touchy-feely language given the time. Pott did care about these patients more than most. The association between this cancer, soot, and the awful life of a young chimney sweep did eventually lead to changes, albeit way slower than you’d like to imagine. Pott’s work was foundational in changing the social consideration for this job. It took an absurd amount of legislative baby steps to finally stop legally stuffing orphans into chimneys. The first was the Chimney Sweepers Act in 1788 (the year Pott died) which aimed to “protect” child workers. It did this by ensuring the minimum working age was raised to a far more respectable eight years old. In 1803, societies were formed to bring awareness to this problem. Succinct names for things had not been invented yet, so the English of the time came up with the following organization: The Society for Superseding the Necessity of Climbing Boys by Encouraging a New Method of Sweeping Chimeys and for Improving the Condition of Children and Others Employed by Chimney Sweepers. (which could go by the unpronounceable acronym, the SSNCBENMSCICCOECS). Acronyms were probably new then, too? In 1834, British parliament passed the “Act for the Better Regulation of Chimney Sweepers and their Apprentices” as well as the “Act for Safer Construction of Chimneys and Flues”. This raised the minimum working age to a double digit, ten years old! In 1840, legislators were all like, “FINE” and raised the working age to 16 years old with the kind recommendation that nobody under 21 should work in the chimney sweeping industry. As almost rational as this sounds, apparently nobody bothered to enforce all of these laws to this point. A commission at this time actually found that all of these bills and acts and whatnot somehow contributed to an INCREASE in child labor so that wasn’t good. Finally in 1875, almost 100 years post Pott’s death, an Act of Parliament forbade children of any sort of working in the chimney sweeping industry. What do you know? The rates of scrotal carcinoma dropped off precipitously. In the 1940’s, St. Bart’s, Pott’s old hospital, reported one single case in 5000 new cancers diagnosed. It turns out that preventing children from laboring in an actual slurry of carcinogens was a good thing. You might wonder, as I did, why it took so long to see the light on this one? Well, have you considered that some people were Pro-Dangerous-Child-Labor at the time? Who was in that camp? More people than there should have been. Insurance companies of the time defended the child labor practices because they did such a good job of sacrificing themselves for cleaner chimneys. There were some mechanical devices suggested to do the job instead of kids, but the companies felt more fires resulted in the chimneys NOT cleaned by children so this was a hit to their bottom line. And have you considered the problematic but lucrative partnerships between the orphanages, parishes, and master chimney sweeps of the time? Master sweeps were paid to take on “local strays” and give them gainful employment and often sourced their employees from orphanages and parishes. I can only imagine the world of horrors that unfolded in those relationships. Lastly, there was some description of public perception that, while shortening the life spans of many of the youngest and most vulnerable members of society was regrettable, it had to be weighed against the dangers to society of having chimneys catch fire more often. I can almost respect the cold logic of that position, but I have to say I’m firmly in the camp of looking for solutions that don’t involve increasing child mortality, I don’t know about you guys. Finally, I wanted to wrap up with a brief tour of Pott’s other contributions to medicine. I mentioned that he has many, many things named after him. I wonder if you guys remember some of them? Pott’s eponym collection Pott’s Spine (aka Pott’s disease) - Tuberculosis infection of the spine and all the associated complications such as “cold abscesses” Pott’s Fracture - Ankle fracture of distal fibula that allows subluxation of the talus laterally since medial ligaments are wrecked. We’ve probably all treated this. He’s considered to be a father of orthopedics as well. Pott’s Gangrene - Basically gangrene caused chronically by end artery disease of the legs. Pott’s Puffy Tumor - Not a tumor but rather the word for swelling. Subperiosteal abscess due to frontal skull osteomyelitis. Sinusitis complication. Forehead swelling, fever, headaches, nasal discharge, possible increased ICP. Apparently wrestling is listed as a risk factor due to punches to the head? Sources: -https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1037746/?page=1 -http://www.whonamedit.com/doctor.cfm/1103.html -https://en.wikipedia.org/wiki/Percivall_Pott -https://en.wikipedia.org/wiki/Worshipful_Company_of_Barbers -https://en.wikipedia.org/wiki/Chimney_sweeps%27_carcinoma -https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1008067/figure/F2/ (Chimney Sweep Pic) -https://www.historic-uk.com/CultureUK/History-Boy-Chimney-Sweep/ -https://www.ncbi.nlm.nih.gov/books/NBK538331/ (Pott’s Disease) -https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5531910/ (Pott’s Fracture) -https://jdc.jefferson.edu/cgi/viewcontent.cgi?article=1008&context=dacosta_modernsurgery (Pott’s gangrene) -https://www.ncbi.nlm.nih.gov/books/NBK560789/ (Pott’s Puffy Tumor) Dr. Max Doctor with a mustache Imagine you’re working the day shift at Bellevue Hospital in New York City–incidentally, since this is a history podcast, the oldest public hospital in the US. It’s hot outside, and it’s Monday, so we all know what that means–plus, let’s give you a little hint that this case isn’t that recent, so, you’re dealing with your standard poor sick person dumps, about six of them, from outlying private hospitals, when the ambulances bring you a case…a young, professional woman is brought in from one of the office buildings near-by with severe stomach pain. The ambulance crew says she was fine this morning, but now she’s got severe cramping pain, and severe gastric emptying. She says she has some tingling in her hands and feet as well. Blood pressure’s low, heart rate’s high…what are your thoughts? Step one–questions from Max and Mike mortality from abdominal pain in general–higher than chest pain gastric emptying and pain out of proportion–mesenteric ischemia, cases in the literature of ‘sudden gastroenteritis’ Step two–escalation You’re just one of the lowly house officers trying to take care of this sick patient at Bellevue, but then you notice a commotion and ask your senior what’s going on. Apparently there’s an office building about eight blocks away that’s in a bunch of trouble; while you’ve been caring for this patient, two more ambulances at least have come from the same place, with patients that have the same symptoms. There are many people sick, all with vomiting and diarrhea. Does this change your differential? How so? Let’s say it’s the early 20th century, so, no joke, your boss at Bellevue says, how about we grab the stomach pumps and go take care of these people in the office building itself? Sounds great! The stomach pump, as a brief aside, was invented by Alexander Munro Secundus–Secundus to differentiate between his father, Alexander Munro Primus, and his son, Alexander Munro Tertius, all of whom held the chair of Anatomy at the University of Edinburgh in the 1700s. Munro Secundus was the most highly regarded, and, in 1767, along with the thinking of the time which fixated on emptying the bowels in one way or another, he invented the stomach pump, which is literally a hydraulic device about the size of a clarinet attached to a rubber tube that is used to manually empty the stomach. Gentleman, have you ever pumped a stomach? These were still in use into the last century; in this case, somehow or another it became clear that there was a huge emergency going on at this office building, with people literally on every floor just emptying themselves, and multiple teams of doctors running around with stomach pumps performing ‘patient care’ (in air quotes). Once the dust cleared, six people were dead, and dozens had become sick, with one of the deaths the original ‘index case’, as it were. What could have possibly happened? Thoughts? The doctors on scene, once done administering care, compared notes, and the medical examiners and so on started to get involved and try to piece together what had happened. They were able to compare notes to the point that the found a common thread–all of the people that got sick had eaten at a local restaurant. Lunch counters and small diners were used frequently at the time and probably still are, and a small restaurant called the Shelbourne proved to have served lunch to all the people that got sick. The first woman who got sick, Lillian Goetz, was a stenographer who had a traditional lunch of tongue sandwich (omigod), coffee, and a slice of huckleberry pie. Although I would suspect the tongue sandwich, it proved to be the pie that was the problem; upon testing, the pie crust revealed traces of arsenic, not present in the flour or any of the basic ingredients. They concluded that is was foul play, and the incident was later known as the Shelbourne Restaurant murders–after those who got sick, the Shelbourne was another victim, as it soon closed, and it was said restaurants around the city couldn’t sell Huckleberry pie to save their lives. Arsenic has been on the pod before; white arsenic, which is a metallic powder, was used for ages as a poison mixed into drinks or food, toxic at low doses. Arsenic dissolves completely in water, and 90% of it is absorbed; it achieves peak concentration within an hour, which is really fast for something we eat or drink. Arsenic attaches really strongly to multiple enzymes in the body–enzymes are like little folded proteins that do stuff–and essentially suffocates cells internally so they die, all over, and then also happens to prevent sugar from being either absorbed or made, which is our back up energy system. It’s absorbed first and most in the guts, and then the liver, which causes the symptoms; because of the way it works, those body systems shut down, which is the main cause of death. Also, which such severe emptying, severe electrolyte abnormalities occur, and when your body gets super low on potassium or magnesium, for example, it’ll short-circuit the heart sometimes. Obviously that’s all a gross oversimplification. This case was never solved with regards to the actual poisoner, but the fact that it was proven as arsenic poisoning at all owes to the story of two men who were instrumental in modernizing forensic medicine, especially in New York. It was overall not unusual at all that a poisoner walked away unscathed and was never caught, especially around this time. New York in the early part of the 20th Century was awash in poisons and not really up to speed on toxicologists or medical examiners. A lot of this episode and the story of early forensic medicine in New York is covered really well in a book called ‘The Poisoner’s Handbook: Murder and the Birth of Forensic Medicine in Jazz Age New York’, by Deborah Blum, which came out in 2011–we’ll link it in the show notes. Prior to around 1917, medical examinations in New York were undertaken by coroners. There were not really stringent requirements for the job, and they got paid on commission based on examinations they did. Given politics at the time, which centered on Tammany Hall, famous for corruption, the coroner’s post was a revolving door of undertakers, politicians, and various other odd jobs; they also produced death certificates that listed the cause of death, and they worked on commission, so it was pretty easy to see how this got co-opted. There were some other famous cases that put this in the spotlight–one chloroform case detailed in the book involved like a string of contradictory experts for days–and prosecutors would routinely avoid calling the coroner for murders because the testimony was so hit-or-miss. So around 1917 the state government passed a law that medical examiners had to be qualified; a man named Dr. Charles Norris was second among three qualified applicants, and was the head of laboratory science at Belleview. The transition was NOT smooth; machine politicians in New York City wanted to use the medical examiner job as patronage, just like they had before, and tried to appoint their own applicant. Then, when there was uproar, they actually tried to arraign the three formal applicants including Dr. Norris for violating a law regarding autopsies. At the time, cadavers were supposed to go to medical schools; by performing the autopsy that was required for the medical examiner’s test, the mayor’s office accused the applicants of breaking the law. This bold-faced power grab didn’t work; the mayor at the time chose Norris because he was second just as a last objection, and, luckily for all of us, chose a famously dedicated man who would go on to be known as one of the two dads of forensic toxicology in the US. Norris was famously dedicated, and often spent his own considerable inherited money on the office of the medical examiner; he was motivated by the old romantic belief of public service that sometimes shows up in the Gilded Age, and lived and breathed the improvements in the medical examiner’s office, along with Alexander Gettler, a pioneering chemist who happened to work at Bellevue as well. Gettler had an opposite path to Norris, immigrating from Austria-Hungary at the age of 7 and coming up through Brooklyn to get a doctorate at Columbia. He literally had to invent many of the toxicologic tests that the early medical examiner’s board used, and worked for decades with the office. Sources:
Dr. Aaron Silver Fox Doc Cardiac procedures we take for granted had to be developed by somebody, somewhere. I don’t know how many times Mike or I have had a patient come to the ER having chest pain, diagnosed a “heart attack” knowing that some part of the heart needed more blood flow, called a cardiologist and had that patient whisked out of our department and onto a cath lab table within literal minutes, to have their heart plumbing fixed without surgery. It can certainly be more complicated than that depending on the scenario, but it was not always this way. One of the interesting things that is discussed early in this chapter, is the fact that the heart was something of an afterthought or organ that was of less scientific interest in the 19th century, and it wasn’t until the 20th century that we made significant developments here. It wasn’t until 1912 until an internist named James Horrick even speculated to an assembly of physicians that blockage of the coronary arteries was probably a thing explaining sudden apparent death. Why did it take so long to figure this out and how was his theory received? (We can discuss some basic cardiac circulation and physiology here). “Myocardial infarction,” the medical term for heart attack, was not really coined until 1918. 1929 - Werner Forssman boldly plays with catheters. Can you tell us a bit about this story and what the concerns of his colleagues at the time were? 1958 - Dr. Mason Sones at the Cleveland Clinic decides the venous system is too easy to put a catheter into. Can you tell us how his first foray into the world of sticking catheters into the arterial side of circulation went? Would you say swimmingly or no?
Once the ability to get catheters into arteries was established, how did we figure out how to fix the problems that were found? This could include a thrombus or blood clot, or a narrowing of the artery due to fat and calcium deposits in the walls (called plaques). I think this involves explaining what the verb “Dottering” is because, whether I was supposed to or not, this part of the book made me laugh. I’m not a fan of balloons–too whimsical and noisy for my taste–but they are quite important to the history of cardiac intervention–fixing problems within the plumbing of the heart, especially. Can you explain what balloons have to do with saving lives?
Any time medicine can fix a life threatening problem without sawing through a ribcage under anesthesia, I’m all for it, but before balloons and catheters were used, one of the only options for fixing artery flow problems to the heart was surgical. Still in use in the right circumstances, “open heart surgery” is the term for going into the thoracic cavity and literally tying in new pipelines to the arteries of the heart, now typically using a big vein taken from the leg, the saphenous vein, to make nice new piping. It took a lot of steps to get to this point because, well, it’s hard to do surgery on a moving organ, especially when it’s kind of important to one’s life. What were the baby steps into cardiac surgery, so-to-speak?
Under ideal pre modern circumstances, I believe I read it’s about a 4 minute window to do procedures on the heart. Maybe 12 minutes with hypothermia. Now we can open a heart, replace a valve, ask poor medical students a bunch of questions until they sweat through surgical smocks while observing, and then have plenty of time to close. What made this possible and how was it discovered?
The last frontier of this chapter, fittingly, is heart transplantation. We can now take a heart from one person and give it to another in need. Can you talk about the first surgeons to figure out the steps necessary to do this, Drs. Christian Barnard and Dr. Norman Shumway? Max Doctor with a mustache. The case is a 40-year-old man who was brought to the emergency room in early October for evaluation of lethargy and confusion. He was traveling from Richmond to Philadelphia when he became ill and was found unconscious under the steps of the Baltimore Museum on Baltimore Street in the late afternoon. He was apparently well when he left Richmond at 7 AM. There was no evidence of trauma, and the patient did not smell of alcohol. History. This man worked as a writer. He had no known allergies, coronary artery disease, diabetes, or other systemic illness, and was taking no medication. He had had cholera three months before the current hospitalization. In addition to a history of depression and possibly of opiate abuse, he had a history of alcohol abuse. However he had abstained from drinking for the past 6 months and there was no reported history of seizures or delirium tremens. The patient smoked tobacco on a regular basis and was sexually active with women. There were no known pathologic work exposures. Hospital course: The man was admitted to the hospital for observation. He was initially unresponsive and remained so until approximately 3 AM, when he developed tremulousness and delirium and began having visual hallucinations. He was noted to be drenched with perspiration and to have wide variations in his pulse rate. He remained in this state for the next 28 hours. Early in the morning on the third hospital day, he became tranquil. Results of a physical examination showed a well-developed white male who was calm and appropriate. His skin was warm and diaphoretic. His pulse rate was in the 50s and “thready.” Results of a neurologic examination showed the patient was alert, oriented, and appropriate. There was no tremor and he followed commands appropriately. The patient said he felt “miserable,” but denied specific pain. He did complain of mild diffuse abdominal discomfort and headache. He had no recollection of how he had arrived at the hospital or of the events leading up to his illness. Because of his improving status, he was transferred to the ward room. Here, his physicians attempted to treat him with alcohol, which he vehemently refused to drink. He soon worsened again and by the evening of the third hospital day, his mental status became clouded. He was noted to have shallow, rapid respiration and diffuse weakness. He drank water only with great difficulty. By late evening, he was again delirious, became combative, and required restraint. He remained in this state, calling out for family and friends, until his death on the fourth hospital day. Differentials, gentlemen? So what do you think ultimately happened here and who is this? If you know me well enough, it won’t surprise you to hear that according to the decor of my house, I think it should be Halloween all year long. So as much as I wanted to save this story for October, I thought it was as good a time as any to discuss the mysterious death of Edgar Allen Poe as it pertains to medical history. Do either of you know how he may have died off the top of your head? I’m not the first to do this sort of case study thing. In fact, the case I gave here was entirely excerpted from a pathology conference that took place in 1996.
A little background on Edgar. Born in Boston in 1806 and did a bit of writing in his life. He also spells his middle name “Allan” with an A in the middle which is weird to me for some reason. Nevertheless, Poe is a huge figure in American literature. He’s associated with macabre fiction and some consider him to be the founder of the detective genre. He’s a notable short story writer and poet but have you even read and appreciated his literary criticism? My inner English-major literary critic and pedantic self would point out that his fiction, though iconic, is a bit formulaic in execution. But that doesn’t matter because he nailed it as far as creating a whole mood of writing that young angsty me and all of my fellow English-major nerdy goth friends will always have a fond place for the Raven and the Telltale Heart because it’s just so good. How could it not be? He was the child of two actors making him an ultimate theater-kid. Notably his father abandoned the family when Poe was 4 years old and his mother died from tuberculosis when he was 5 years old. An uncle ultimately raised him and gave him the official name “Edgar Allen Poe” because he would have been otherwise called just “Edgar Poe” and “hello, my name is Ed Poe” just wouldn’t carry the same literary weight. Many people also know some of the salacious things about EAP. Like, say, that he married his 13 year old cousin which–I know it was a different time–but all of that just seems skeezy. He dallied around in some college at the University of Virginia and eventually dropped out of West Point, turning his career to writing and the rest was history. So here’s the historical account of EAP’s demise. On Sept. 27th, 1849, Edgar traveled from Richmond, VA to Philadelphia where he was supposed to arrive to critique the poetry of Marguerite St. Leon Loud, a writer who has four names and punctuation within their name and writes poetry, a statement of fact that can be a joke in and of itself. He takes the train which passes through Baltimore. He was supposed to continue on to New York after all of the difficult poetry critiquing, but he did not make it because of dying in Baltimore. In his personal life, aside from having a creepy if not criminal marriage, Poe has been described as having an on and off relationship with Laudanum–the opium alcohol mixture so popular among people of the time. If you enjoyed the series, Deadwood–and you should have–you will be familiar with this medication and its abuse potential. You will also be benumbed to lots of old west swearing. There are varying accounts as to whether Poe was a drinker. Nothing seemed to suggest a heavy alcohol problem in terms of volume, but rather that he (and his sister oddly enough) may have been very sensitive to alcohol, being described as appearing heavily intoxicated and ill after a single drink. For some reason he would do that on occasion but apparently had joined the Sons of Temperance movement just prior to his death. They were not known for wild parties I would like to point out. So Poe arrived in Baltimore on Sept 27th and goes missing for a week. Nobody sees him. Then on the evening of October 3rd, 1849, a guy named James Walker happens to be standing on the street when he comes across a disheveled man in ill-fitting clothing lying in the gutter. Walker is like, “Oh, that’s Edgar Allen Poe” and he doesn’t look too good, I’d better get help.” Help comes in the form of dispatching a letter–albeit with most haste–that same evening. 911 or a true sense of medical urgency had not been invented yet. Walker, finding Poe in bad apparent shape, asks if he knows anyone in Baltimore and Poe gives him the name “Snodgrass.” Though Poe appeared to be altered or in some sort of stupor, that was actually a real name for Joseph Snodgrass (who, some articles suggested, was a physician as well as a magazine editor familiar with Poe). Snodgrass receives the following letter: Baltimore City, Oct. 3, 1849 Dear Sir, There is a gentleman, rather the worse for wear, at Ryan's 4th ward polls, who goes under the cognomen of Edgar A. Poe, and who appears in great distress, & he says he is acquainted with you, he is in need of immediate assistance. Yours, in haste, JOS. W. WALKER To Dr. J.E. Snodgrass. So EAP ends up in the hospital as per the case in the beginning and ultimately dies. There are many theories which we’ll talk about. Trauma or Assault? Finding a guy disheveled and altered in a gutter could certainly mean trauma. This is as true today as it was in 1849. One theory were that he could have been the victim of some unspecified “ruffians” in the streets of Philadelphia. Today those ruffians are known as the “two dudes” who roam around the streets causing all manner of trauma on unsuspecting people who definitely are telling the truth about what they were doing. None of the accounts I found suggested any outward head trauma stuff but certainly other areas of injury might be possible. There was also a book suggesting that Poe was murdered by the brothers of his wealthy fiancee, Sarah Elmira Shelton that he was going to apparently marry after some point, but he was still married to his cousin, Virginia–I don’t know all the details here, nor do I care to. Apparently the brothers of the new fiancee were not happy and may have murdered him somehow by making him drink or whatnot. Not a lot of support for this one but it’s salacious so why not consider it? Alcohol or Substance Related? We mentioned that Poe had an intermittent relationship with alcohol and this was suggested as an issue on and off in his life. Again, he seemed to be unable to tolerate small amounts. When he disappeared for a week, some stories suggested he may have met up with some old friends and gone out drinking before reappearing in bad shape. Some of these articles suggested the theory that he was encouraged to drink enough to die. It’s mentioned that he’s sensitive to alcohol and there are conditions such as alcohol dehydrogenase deficiency–indeed genetic–that could make one become very ill or intoxicated out of proportion to their intake, but it typically takes large amounts of alcohol quickly to die from so-called alcohol poisoning. Mixing alcohol with laudanum could certainly kill somebody, but this would be in the form of respiratory arrest, not days of stupor and intermittent hallucination. This theory was also perpetuated by Snodgrass, his editor after Poe’s death. Snodgrass was a member of the temperance movement and suggested binge drinking was at play. Interestingly some forensics were done on Edgar by sampling his hair for heavy metals–lead was a common contaminant in wine and alcohol at that time and collected in hair. Many think Snodgrass had it out for Poe in a sort of self-promotional self-righteous way. Not cool if true. Voter Fraud? A subset of the trauma / assault theory is that he may have been a victim of voter fraud in a practice called “cooping.” Philadelphia politics were rough, it seems, back then. Probably still are–I’ve never voted there. Apparently there were roving gangs (ruffians or otherwise) that would kidnap people, force them to vote, change their clothes, force them to vote again with a forged identity, and repeat the process with intermittent forcing of alcohol. Where Poe was found was apparently outside a polling station on Election day. This was–and perhaps still is–a leading theory to explain his death, including his 1870’s biographer, J.H. Ingram. Given his suspected low tolerance for alcohol, perhaps there’s something here? Brain Tumor? This theory has my favorite supporting evidence–not because it’s true, necessarily, but because it’s got a dark Naked Gun kind of flair to it. 23 years after Poe’s death they want to put a statue there at his grave so they decide to move the body. When they dig up the coffin and lift it, apparently it falls apart due to decay. Poe’s body is similarly in bad shape and when his skull falls out, a worker commented that it’s as if he heard or felt a lump of something rolling around inside it. While some newspapers at the time said it was his brain, 23 years later it was definitely not brain tissue. It could have been a calcified tumor, however. Not sure a brain tumor would explain the entire story and it’s pure speculation at this point because nobody, as far as has been said, wanted to open up the skull at the time. I would have wanted to, but I’m a weird guy. Also possible he did have a brain tumor that had nothing to do with any of this. Flu? His official diagnosis was reportedly “phrenitis”. The Phren prefix refers to “mind”. So that’s mind-itis. I want to write that in a chart. We don’t use this term anymore and would now probably refer to the symptoms of phrenitis as encephalitis or meningitis. This is often due to infection–be it viral or bacterial–and means inflammation of the brain, the lining of the brain, or both in the case of meningoencephalitis. It’s a bad thing, medically speaking. This raises the question as to whether Poe might have had symptoms of brain inflammation–probably more akin to encephalitis which tends to give people altered sensation or hallucinations or both. What could do this? A helluva lot of viruses both common and rare. October is the beginning of flu season so some speculation is that he may have developed influenza related encephalitis and pneumonia. Apparently in Richmond, before leaving for Philly, he did visit his doctor complaining of illness. The Smithsonian magazine quoted that “His last night in town, he was very sick, and his [soon-to-be] wife noted he had a weak pulse, a fever, and she didn’t think he should take the journey to Philadelphia.” She was probably also worried about ruffians. So if he did have influenza and pneumonia, he might have been septic. A high fever could give you hallucinations and brain swelling–encephalitis–can make you seem to go in and out of consciousness and whatnot and can certainly lead to death. It does not make you wear other people’s clothes, however. Rabies: Returning to that pathology conference, Dr. Benitez hypothesized that this may have indeed been rabies encephalitis. Noting there was no animal encounter in the story, there is not always one mentioned. Just waking up in a room with a bat is indication to give someone rabies prophylaxis injections because often a bite from a rabid bat may not be visible, nor felt. For the record I think bats are super cute and I enjoy watching them do bat things from my porch, but I do not invite them into my home for this reason. The other scary thing is that rabies is a very, very slow moving virus. If bitten in an extremity, the virus, which gets absorbed into the skin and makes its way to the nervous system, can take up to a year to appear with symptoms–at this point it has traveled super slowly from the nerve in the arm or leg into the brain. With modern medicine, the first person to survive rabies did so in 2004. We should probably save that story for a future episode, but I can’t resist pointing out that she was saved by a treatment plan now called “the Milwaukee Protocol.” Milwaukee brought you Pabst and survival from rabies. You’re welcome. Poe had many of the symptoms of rabies including lethargy, confusion, a waxing/waning sort of downward spiral, and as was mentioned, there was perhaps some difficulty taking fluids and water. Those infected with rabies have severe pain with swallowing and often are salivating because they can’t even swallow their own spit. That spit is rife with rabies virus as well so a bite from an animal perpetuates the horror of this illness. So that is the story of Edgar Allan Poe and his suspected actual cause of death, probably because there was no autopsy and this happened a long time ago. Sources: https://blog.oup.com/2014/10/edgar-allan-poe-death-diagnosis/ https://archive.hshsl.umaryland.edu/bitstream/handle/10713/6824/EdgarAllenPoe_1995.pdf?sequence=1&isAllowed=y https://cvm.missouri.edu/quoth-the-raven-it-was-actually-rabies/ https://www.smithsonianmag.com/history/still-mysterious-death-edgar-allan-poe-180952936/ https://www.biography.com/authors-writers/edgar-allan-poe-death https://www.mdhistory.org/here-at-last-he-is-happy-the-death-and-burial-of-edgar-allan-poe/ Max Doctor with a mustache. Mary Mallon was born in 1869 in Cookstown, County Tyrone, in what is now Northern Ireland. She emigrated to the United States at the age of 15, a common choice for women like her in the late-1800s. After living with her aunt and uncle for a time, she eventually settled into her career as a cook for wealthier families. Over the course of seven years, Mallon worked as a cook for eight affluent families in the New York City area. This was a good job for someone in her position as it would have paid far more than, say, being a maid or laundry worker. Mallon never showed any signs or symptoms of illness, but over the years of her employment, seven families she worked for contracted typhoid fever. A deadly pattern formed. Mallon would move into a new household, and within a few weeks of her arrival, people would be seriously ill with typhoid fever. 1906: multiple ill people with typhoid in a house in Long Island. Long island public health could not identify the cause of the outbreak so the homeowner hired George Soper of New York's health department. Mary Mallon had just started working as a cook for the family 3 weeks prior to the outbreak. Soper looked at the files regarding outbreaks and noticed that Mary Mallon worked at each of the houses and the outbreaks started shortly after her arrival. She refused to wash her hands while cooking because she "didn't see the point". Soper went to the house to tell Mallon about his findings and offered her free medical care and asked for samples for testing. She chased him out of the house with a rolling pin. Soper sent a medical team to the house and she fled. Police searched for her for 3 hours. At this point she had infected 22 people and one little girl had died from the infection. Soper offered to release her if she had her gallbladder out or stopped working as a cook. She refused both and was labelled a "menace to society". She was banished to Riverside Hospital for Communicable Diseases on north brother island to live in solitude. She was there for 3 years and was ultimately released by a new health comissioner after many failed legal attempts. She eluded authorities for 5 years and continued to cook. She was found cooking at Sloan Maternity Hospital in New York where 25 new cases of typhoid fever had been reported. She was sent back to North Brother Island where she spent the rest of her life. She died on 11/11/1938 after 26 years of forced isolation. She infected 51 people, 3 of whom who died. By the time she died New York health officials had identified more than 400 other healthy carriers but no one else was forcibly confined. Sources: - Journal Article: The Sad and Tragic Life of Typhoid Mary - Wikipedia: https://en.wikipedia.org/wiki/Mary_Mallon - The Story of Typhoid Mary is Way Sadder Than You Think - PBS (NOVA) Documentary on YouTube: Typhoid Mary: The Most Dangerous Woman Dr. Mike (aka Dr. Provolone) Germ theory is the idea that you can’t have infectious disease without some kind of disease causing pathogen, and it’s the basis behind every modern treatment from vaccines to antibiotics. And there are two big scientists who get most of the credit for advancing germ theory in the late 1800s — Louis Pasteur from France, and Robert Koch from Germany. And before I made the videos, I knew these two guys were around at somewhat the same time, but I didn’t realize just how much their rivalry actually advanced germ theory. So today, I’m going to give you a little background on each of them, go into more detail for their first public smackdown, and how their legacies took on rivalries of their own. But before we go any further, I know the proper German pronunciation is Koh, but it’s hard to say that sound in American English. Guys, do you want to give it a try? German listeners, I’m sorry. Their beef really starts in the 1870s and revolves mainly around the discovery of anthrax, but we need some character development first. Some quick backgroundBy the 1870s, Pasteur was already a well known scientist internationally, and the leading scientist in this new field of bacteriology. He got his start as a chemist and first got popular thanks to his discovery of a property called chirality. This is where some molecules or crystals have handedness, or mirror opposite versions of themselves. He also showed that the process of fermentation happens thanks to the actions of microbes, which settled a debate about whether fermentation was entirely chemical or if biology was involved. He published two big papers on the topic — one on lactic acid in 1857, and another on alcohol fermentation in 1858. He also did a famous experiment where he debunked a super old idea called spontaneous generation, the idea that living things can come from nonliving things. Part of the experiment involved taking custom-made flasks, filling them with broth, and heating them up to kill off the existing bacteria inside — this made sure he was starting the experiment with a blank slate. And since his early work on fermentation showed that microbes caused milk and beer to spoil, he got the idea that you could blast the milk, or wine or whatever with some heat, kill off the microbes, and delay spoiling. He published his paper on the topic in 1863 and finally, patented this process of pasteurization in 1865. [Max] opportunity to plug Lister episode since Lister started reading Pasteur in 1864 — around this time in the story. So going into the 1870s Pasteur already had a mega successful career. He’d revolutionized both food preservation and inspired Lister’s revolution in surgery. And later in the late 1860s, he helped figure out how to stop an epidemic among France’s silkworms, which helped France’s economy, since they exported quite a bit of silk. Enter Robert Koch. He was twenty years younger than Pasteur and studied under an anatomist you might not realize you’ve heard of: Friedrich Gustav Jakob Henle. Can you three name the anatomical structure he’s known for? Well in 1840, he also came up with a set of criteria he’d use to show that a microbe caused a disease. You had to consistently find the microbe alongside the disease, you have to isolate the microbe from living tissues, then it has to produce disease when you give it to test animals. These criteria became known as Henle’s Postulates. So Koch graduates from school and was primed to look for germs as the cause of disease, but other than having a well respected teacher he didn’t have any big accolades before going into our next chapter which is anthrax. AnthraxKoch starts working out in the countryside where local livestock are getting wrecked by anthrax. Anthrax is a rod shaped bacteria that can turn into a little spore outside of its host, and live dormant for long periods of time. There are a bunch of different ways of getting it, like through breaks in the skin or through the GI tract. Then when they get into a body, they reactivate and turn into their pathogenic form, and can kill their host within 36 to 72 hours. LIke sometimes the first time you’d recognize your cattle had anthrax was when a couple just dropped dead. And a few years earlier, a separate rivalry of French and German scientists found a bacteria that tended to show up in anthrax. The Germans named it Bacillus anthracis while the French scientist called it Bacteridium anthracis. And given his mentor’s postulates, if Koch found the bacillus, he could show not just an association, but a cause and effect relationship. Sure enough, he finds B. Anthracis in a bunch of cows and sheeps that he dissects. Then he does something cool and puts the bacteria into cow eyeball fluid, which gets the bacteria to multiply. This is called a culture of bacteria. Then he took that culture and injected it into experimental mice and they developed anthrax. And that was a big deal because for the first time, someone tested the idea that a specific germ caused a specific disease, which is the central idea in germ theory. He published his first anthrax paper in 1876 and published again in 1877. And it was a big hit right away. Then in 1878, Koch followed in his mentor’s footsteps and published his own postulates for disease causation. Basically, here’s how you might tell whether germ x causes disease y. So at this point, Koch is player on the international science stage, which got Pasteur’s attention. Koch mentioned in his report that the anthrax bacteria form these little spores which let them survive outside of their host, but couldn't figure out how that spore made their host sick. He just knew that when you injected the culture back into an animal, it got anthrax. So in 1878, Pasteur’s lab basically repeated Koch’s experiments, but used a slightly different technique. From that, Pasteur reasoned that the anthrax spore morphed into the rod shaped, infectious bacillus in the body, which then caused disease. In an 1878 summary paper to the Academy of Sciences, Pasteur says: “I ask the Academy not to dismiss these curious results before I demonstrate one important theoretical conclusion. We insist on demonstrating at the start of these studies (that are opening a whole new world of knowledge) a proof that the cause of transmissible, contagious and infectious diseases resides essentially and uniquely in the presence of microorganisms”. However, Pasteur doesn’t really acknowledge Koch’s recent work. He uses French nomenclature, Bacteridia anthracis, and doesn’t really acknowledge Koch’s recent work. That’s less to do with any personal beef they have, and more to do with national rivalries — they were coming off of the Franco Prussian war in the 1870s, which France lost. In 1879, Pasteur and his team developed a vaccine against chicken cholera by exposing the germ to the air repeatedly. Those new, weaker cultures weren’t able to cause disease as easily as the normal bacteria, giving us the process of attenuation, which is still used today. This was a different strategy than variolation and Jenner’s vaccination against smallpox. Chicken cholera was caused by a bacteria that they could study outside of a body. And if they could manipulate the germ, they could manipulate the course of disease. Pasteur started working on an anthrax vaccine next, but it behaved differently than chicken cholera. Since B. anthracis forms a spore when exposed to air, it didn’t matter how many times the Pasteur lab cultured the bacillus; they couldn’t create a weaker version. I mean, when you consider they can live dormant underground for literally decades, it’s no surprise that repeated exposure to air didn’t reduce virulence. So they decide to add some heat, and found that 42 to 43 celsius was just right for keeping the culture alive and replicating, but making it less virulent. In May 1881, Pasteur did a public experiment where he took 50 sheep and gave them all anthrax after vaccinating half of them against the disease. Sure enough, the vaccinated half all lived while the unvaccinated half all died. He got a ton of publicity for it, and stole the spotlight back from Koch. Koch responds by saying: “Pasteur follows the tactic of communicating only favorable aspects of his experiments, and of ignoring even decisive unfavorable results. Such behavior may be appropriate for commercial advertising, but in science it must be totally rejected…. His behavior is simply inexplicable”. From here, their careers split paths, but in kind of parallel tracks.Pasteur creates a rabies vaccine using a method more similar to the chicken cholera vaccine with the repeated cultures, but grown in dog and rabbit brain tissue. Rabies wasn’t affecting a ton of people, but it was an emotionally charged disease. Koch finds the causative germ of tuberculosis and published his results in 1882, then another TB paper in 1884, which is when he updates Koch’s Postulates. In contrast to rabies, tuberculosis was a massive cause of mortality, and is still the leading cause of death from any infectious disease today. Koch also found that Vibrio cholerae causes cholera. In 1885, Pasteur opened the first Pasteur Institute in Paris, which was the first research center for biomedical science. It’s there where researchers start using the term microbiology instead of bacteriology. Koch decides he’s going to do his own research, independent of government funding, and instead fund it through applied research. Basically, a pharma company funding the research. In 1890, comes out with tuberculin, which he touted as a TB treatment. It turned out to be ineffective, but we still use it today as the TB skin test. It was a pretty big embarrassment, but his reputation could take it. In 1891, he opened the Robert Koch Institute in Berlin with funding from the government. Pasteur died in 1895 but Koch, who was 20 years younger, had one more grand round in him. In 1896, he did a world tour and learns more about acquired immunity. He died in 1910 LegaciesBut even in death, their legacies have a rivalry through the institutes that they founded. First up was diphtheria — a team of Koch’s students finds the diphtheria toxin, and one of them Emil Von Behring, starts working on a weakened antitoxin to create a vaccine. One of Pasteur’s close assistants and collaborators, Emile Roux, came up with a different serum therapy, using horses’ blood to produce it. Next, syphilis. Paul Ehrlich was a student and collaborator with Koch. After his time at the Koch Institute, he did a bunch of work with dyes which led him to salvarsan, which is one of the first effective antibiotics, albeit a narrow-use one. But syphilis was a big problem at the time, and antibiotics would become a much bigger deal. Then, there was plague: One of the scientists who worked with Roux on diphtheria at the Pasteur Institute was a guy named Alexandre Yersin, who you might know as the namesake of Yersinia pestis, which he identified after leaving the Pasteur Institute. Then we go back to Tuberculosis. While Koch tried to cure tuberculosis with his failed tuberculin treatment, it was two french scientists at the Pasteur Institute who spent the early twentieth century creating a more effective anti-tuberculosis vaccine, called the BCG, which stands for bacille Calmette Guerin. From there, the Pasteur Institute expands globally (including one in NYC) and works on epidemic typhus and typhoid. The RKI unfortunately was used for scientific research during WWII, which meant Nazis. References: 1- germ theory, in medicine, the theory that certain diseases are caused by the invasion of the body by microorganisms https://www.britannica.com/science/germ-theory 2-germ theory: the doctrine that infectious diseases are caused by the presence and activity of microorganisms, such as bacteria, viruses, or fungi, in body tissues. https://dictionary.apa.org/germ-theory 3- His studies on the optical activity and crystallography of these molecules allowed Pasteur to identify their molecular dissymmetry and their mirror-image nature. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9027159/ 4- Among them, Louis Pasteur is certainly the father of molecular chirality (the so-called molecular dissymmetry) https://onlinelibrary.wiley.com/doi/full/10.1002/chir.23349 5- Demonstration of the experiment he used to show chirality at the molecular level. https://youtu.be/ZejAu_uPxMs?t=227 6- The fact that fermentation is part of the action of a living entity had been hypothesized since Antoine van Leeuwenhoek (1623-1723) observed yeast under a microscope in 1680. The link between these cells and the fermentation process was described in 1787 by Adamo Fabroni https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9027159/ 7- In 1856, Pasteur was able to observe the microbes responsible for alcoholic fermentation under a microscope, as a professor of science in the University of Lille. https://en.m.wikipedia.org/wiki/Fermentation_theory 8- Pasteur began his research in the topic by repeating and confirming works of Theodor Schwann, who demonstrated a decade earlier that yeast were alive. https://en.wikipedia.org/wiki/Louis_Pasteur 9- Well, what he did was to discover that the fermentation was caused instead by living microorganisms, bacteria that he identified through the microscope. Now, this was a high-profile investigation in the 1860s, for the simple reason that the production of wine and beer involved two of France’s major economic activities. https://oyc.yale.edu/history/hist-234/lecture-14 10- Thus, he accumulated observations consistent with his hypothesis that lactic fermentation occurs in the presence of living organisms. https://www.frontiersin.org/articles/10.3389/fimmu.2012.00068/full 11-But in 1857, Pasteur proved that a microscopic plant caused the souring of milk (lactic acid fermentation). Pasteur was able to prove that living cells, the yeast, were responsible for forming alcohol from sugar, and that contaminating microorganisms found in ordinary air could turn the fermentations sour. https://lemelson.mit.edu/resources/louis-pasteur 12- Primary source! https://ssaal.univ-lille.fr/wp-content/uploads/2014/07/Sol_2007_p8-15_lactique1.pdf 13- Spontaneous generation or abiogenesis, the idea that living things could arise from inanimate objects, dates back to Aristotle in the fourth century BC…. Organisms such as flies and worms were “observed” to come from lifeless objects such as meat or decaying matter https://www.jstor.org/stable/4451121 14- …he incorporated the use of the now famous swan necked flasks in his experimental research. Swan-necked flasks permitted him to boil the broth and allow “natural air” to enter; however, these flasks prevented airborne microbes from reaching the broth, and thus the broth remained free of microbial growth https://www.jstor.org/stable/4451121 15- Pasteur's research also showed that the growth of microorganisms was responsible for spoiling beverages, such as beer, wine and milk. With this established, he invented a process in which liquids such as milk were heated to a temperature between 60 and 100 °C. https://en.wikipedia.org/wiki/Louis_Pasteur 16- He developed a protocol to fight the diseases, heating the wine to between 55°C and 60°C, a temperature at which it does not deteriorate and its bouquet is preserved. This method is now known worldwide as pasteurization. https://www.pasteur.fr/en/institut-pasteur/history/middle-years-1862-1877 17- Pasteur and Claude Bernard completed tests on blood and urine on 20 April 1862.[67] Pasteur patented the process, to fight the "diseases" of wine, in 1865.[66] The method became known as pasteurization, and was soon applied to beer and milk. https://en.wikipedia.org/wiki/Louis_Pasteur 18- In 1864, while working at Glasgow University as Professor of Surgery, Lister was introduced to Pasteur’s germ theory of disease, and he decided to apply it to the problem of surgical infections. 19-During this time, which spanned the Franco-Prussian war of 1870, the end of the Second Empire and the start of the Third Republic, Pasteur became the equivalent of a “rock star,” essentially a household word and the epitome of a scientist, as well as a national hero. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3342039/ 20-Pasteur had already discovered molecular chirality, investigated fermentation, refuted spontaneous generation, inspired Lister's introduction of antisepsis to surgery, introduced pasteurization to France's wine industry, answered the silkworm diseases blighting France's silkworm industry https://en.m.wikipedia.org/wiki/Koch%E2%80%93Pasteur_rivalry 21- Let us begin with Robert Koch himself, who was born December 11, 1843, the son of a mining engineer. Koch studied medicine at the University of Göttingen, where he was influenced by Jacob Henle, the professor of anatomy who had published in 1840 on the possible relationship of microorganisms to disease and who name is often linked with Koch’s in discussions of the postulates https://www.jstor.org/stable/23331663 22- In 1840, Jakob Henle enunciated the concepts of causation in a book which has been translated into English by Dr. George Rosen (1). Henle was then 31 years old and just starting his duties as professor of anatomy in Zurich https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2595276/pdf/yjbm00143-0072.pdf 23- If the inoculated person or animal did not die and therefore no autopsy could be performed, one could not always determine with certainty whether the disease produced in the second instance was the same as that in the original case https://www-jstor-org.harker.idm.oclc.org/stable/pdf/24618980.pdf?refreqid=fastly-default%3A77514f395d9aa05ef04e45dfd348e059&ab_segments=0%2Fbasic_search_gsv2%2Fcontrol&origin=&initiator=search-results&acceptTC=1 24- The organism must be found constantly in association with the disease, and in the living tissues; it must be isolated; it must then be tested by experiments, including animal inoculation. https://www.jstor.org/stable/43428369 25- In his spare time, Robert Koch began researching into anthrax: around Wollstein, the disease regularly claimed the lives of both animals and humans – but the cause was completely unknown. https://www.rki.de/EN/Content/Institute/History/rk_node_en.html 26- A large, gram-positive, rod (bacillus), Bacillus anthracis is the causative agent of anthrax (Greek for “coal”), named for the black lesions of cutaneous anthrax. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6860146/ 27- The first form is due to a microbe called Bacteridium anthracis 28- In doing so, Robert Koch was the first to prove that a microorganism was the cause of an infectious disease. https://www.rki.de/EN/Content/Institute/History/rk_node_en.html 29-Two years later, in 1878, Koch published two papers on wound infections. He utilized similar absence arguments as the basis for proving bacterial etiology. In the second paper, Koch laid out for the first time his specific criteria for establishing causation — the first statement of his postulates. https://www.jstor.org/stable/23331663 30-Koch had transformed bacteriology by introducing the technique of pure culture, whereby he established the microbial cause of the disease anthrax (1876) https://en.m.wikipedia.org/wiki/Koch%E2%80%93Pasteur_rivalry 31- He discovered the dormant stage of the pathogen, anthrax spores, and thus unraveled the previously unexplained chain of infection and the bacterium’s strong resistance to environmental factors. 32- He was the first to succeed in changing the thread-like microscopical corpuscles identified by others into identifiable long filaments (chains of rods) and then into beads consisting of minute grains, the spores…. Of course, as a result of Koch’s experiments, now we know that the ability of the microbe to sporulate enables it to withstand harsh temperatures and conditions that occur during the winter months. https://www.frontiersin.org/articles/10.3389/fimmu.2012.00068/full#h4 33-He repeated the same process used by Koch: successive dilution--essentially taking a few drops from a flask in which he grew anthrax, diluting it in a new flask, over and over, until there was no doubt that every other potentially contagious element had disappeared then injecting the pure culture into host animals, who reliably contracted the disease. Miracle Cure p26 34- The endospores discovered by Koch were the reason that seemingly dead bacteria remained carriers of disease: Anthrax cells weren't killed by oxygen, but simply became dormant inside the walls of a spore. The groundbreaking understanding of anthrax- a combination of Koch's spores and Pasteur's dilutions- was the first to link the German physician with the French chemist. It would not be the last.” Miracle Cure p26 35- Two years after Koch’s publication proving the microbial nature of anthrax, Pasteur presented a Summary to the Sessions of the Academy of Sciences (Pasteur et al., 1878). According to Pasteur: https://www.frontiersin.org/articles/10.3389/fimmu.2012.00068/full#h4 36- https://www.frontiersin.org/articles/10.3389/fimmu.2012.00068/full#h4 37- Original French version (no mention of Koch) https://gallica.bnf.fr/ark:/12148/bpt6k15133278 38- English translation of certain sections. He uses the French Bacteridia https://sourcebooks.fordham.edu/mod/1878pasteur-germ.asp 39- https://en.wikipedia.org/wiki/Franco-Prussian_War 40- Pasteur reasoned that exposure to oxygen had caused the loss of virulence. He found that sealed bacterial cultures maintained their virulence, whereas those exposed to air for differing periods of time before inoculation showed a predictable decline in virulence. He named this progressive loss of virulence ‘attenuation’, a term still in use today. https://www.nature.com/articles/d42859-020-00008-5 41- Pasteur, along with Charles Chamberland and Emile Roux, went on to develop a live attenuated vaccine for anthrax. Unlike cultures of the chicken cholera bacterium, Bacillus anthracis cultures exposed to air readily formed spores that remained highly virulent irrespective of culture duration https://www.nature.com/articles/d42859-020-00008-5 42- However, Pasteur discovered that anthrax cultures would grow readily at a temperature of 42–43 °C but were then unable to form spores. These non-sporulating cultures could be maintained at 42–43 °C for 4–6 weeks but exhibited a marked decline in virulence over this period when inoculated into animals. https://www.nature.com/articles/d42859-020-00008-5 43- Miracle Cure p27/28 44-Concomitantly with the work on cholera, Koch investigated the etiology of tuberculosis. IN 1882, he announced the discovery of a bacillus as the cause of the White Plague https://www.jstor.org/stable/23331663 45- TB is the leading infectious disease killer in the world, claiming 1.5 million lives each year. https://www.cdc.gov/globalhealth/newsroom/topics/tb/index.html# 46- 1895 Louis Pasteur died in Villeneuve-l’Étang on September 28. https://www.pasteur.fr/en/institut-pasteur/history 47- From 1896 onwards, Robert Koch spent several months each year on expeditions to investigate tropical diseases – his second wife Hedwig Freiberg nearly always accompanied him. https://www.rki.de/EN/Content/Institute/History/rk_node_en.html 48- At the beginning of April 1910, Robert Koch suffered a massive heart attack in Berlin. He died during a subsequent stay at a sanatorium in Baden-Baden on 27 Mai 1910. https://www.rki.de/EN/Content/Institute/History/rk_node_en.html 49- Not long after the institute's inauguration, Roux, now less occupied in the fight against rabies, resumed in a new lab and with the help of a new colleague, Yersin, his experiments on diphtheria. https://en.wikipedia.org/wiki/Pasteur_Institute Patrick Kelly @PatKellyTeaches Special Guest Episode. Notes above including research and references are the excellent work of Patrick Kelly. Tuberculosis, or TB, is an ancient disease that has been with us from the very start. It’s been found in Peruvian mummies, Egyptian mummies, and burial sites that are almost 10,000 years old, at least in DNA form, and it’s still, today, the single deadliest infectious disease, killing almost a million and a half people a year, back on top this year after COVID played the part of Leicester City in 2020. It has infected about a quarter of the world’s population. We’ll come back to that briefly at the end just to cause some existential dread and we’ll have some links for more reading, but forget all that stuff, what we really want to know is how it affected Victorian England, which I think we’ve established is one of this podcast’s favorite eras–in this case, because it was nutty enough to take the symptoms of this disease and essentially proclaim it sexy as all hell while everyone first tried to figure out what it was, then tried to figure out what to do about it. Let’s do a bit of background, keeping in mind, in the US, as a modern ED doc, I’ve seen probably fewer than five cases of TB. If you’re listening or have a background in Global Medicine, feel free to point out stuff I get wrong for a future shout-out! TB is typically caused by mycobacterium tuberculosis, which is a bacterium, and part of a group of seven or eight closely related bacteria, all of which generally cause similar disease. TB is, first off, really slow. Some bacteria replicate in 20 minutes, but TB takes up to a day to replicate. It also needs lots of oxygen. Its cell wall is basically solid fat. It also doesn’t like to move. Because of all those factors, it tends to set up in the lungs–we’re essentially the only victim of this disease–some forms get into livestock, but really it’s all us. It’s able to trick the immune system into bringing it lunch instead of killing it once it’s absorbed, so it creates these giant cavitary lesions and clumps of cells and gunk from us trying to kill the cells called a granuloma generally, and they get quite large. Characteristically it goes for the upper lungs because that’s where the oxygen is richest. Lazy. This is the laziest bacterial disease I’ve ever heard of. E. Coli is clawing its way up the urethra and TB is just sitting there. Complete trash. A relatively high percentage of people don’t even develop active disease if they are infected–90 percent of people who have normal immune systems control the bacterium after infection and develop no symptoms–and although it’s definitely contagious, it takes a fair amount of exposure to catch it–which is not to say it’s not a problem or safe or whatever. It’s more like that picture of the iceberg where most of it is below the water that you see in PowerPoint shows, with a huge number of people infected but not sick, and even when they are, it takes weeks before they start to show symptoms. Because it’s a slow bacterium, TB is likewise a slow disease, usually, with an initial phase that lasts weeks. The ‘post-primary’ phase often lasts for years, outside of what was called ‘galloping consumption’, and outside of other infections like HIV, and primarily consists of a losing battle between the body and the bacteria. You can kill it with antibiotics but it takes, like, four of them, if you’re lucky, and treatment goes on for months. People are intermittently contagious early on, as the body’s immune system tries and usually fails to clear disease. People then devolve into this classic picture of weight loss and what’s called cachexia, with night sweats, and a bloody cough that Hollywood loves. Most of the consequences have to do with destruction of the lungs, but because it is incompletely cleared and can travel through the bloodstream, it can set up and cause granulomas all over. Today, it’s relatively rare in rich countries, so we don’t see it, and thus we don’t care about it as much as we should in general; the WHO still does, and global health does, but there is a whole historical era heavily influenced by tuberculosis–nineteenth century England. There was a bunch of heinous crap in those days, as we’ve covered, and you could die in all sorts of ways, but tuberculosis captured the imagination in a way few other diseases can rival. Starting in the seventeenth century, people noticed that TB was more and more prevalent, and took to calling it ‘consumption’ because it does literally consume patients–people can’t keep up nutritionally and they lose weight to a staggering degree. In the early 1800s, there was a mandate from parliament to track vital statistics, such as mortality rates, cause of death, and so on. This led to a lot of writings about TB overall, with estimates that the disease accounted for anywhere from a fifth to a third of deaths at the time, probably heightening its fame. TB also coincided with our old friend Theophile Hyacinth Laennec’s invention of the stethoscope, which allowed a significant extension of the physical exam, especially of the lungs, where there were numerous findings in TB patients. In combination with growing anatomist studies which we’ve also covered, there was a whole cottage industry of TB prognostication and guesswork, including new names for types of dead tissue–caseating necrosis is a description of dead tissue in the body that looks like cheese, for example–and many autopsy findings to name in TB patients. Because it was so common, many experts had a lot to say about it, always good for fun with an infectious agent before germ theory. Of course the Victorian English, being Victorian English, related TB to what they called ‘constitutional factors’ which was really just cover for a sort of class-based or inherited theory–you’re sick because you’re inferior, the thinking went. This seemed to be the prevalent view in England and northern Europe, for some reason, while TB was regarded as more infectious in the south. Perhaps because the disease was slow, and some percentage cleared the disease even when infected, people looked for explanations other than contagion; as early as 1806, the doctor John Ried said, “the destroying angel, while requiring general retribution for certain deviations from nature, marks particular individuals for primary sacrifice”. This was reinforced with cases like the Bronte family; Emily Bronte, who penned the famous Wuthering Heights, her only novel, published to great acclaim in 1847, was one of the younger sisters. It was her only book, and it was apparently so passionate everyone thought a man wrote it at first. Her whole family died of TB, and rather than look at the fact that they all drank water that drained out of the church graveyard next door or that, you know, TB is contagious, chose to say, oh, well, she was quiet, shy, and retiring, and obviously didn’t have a strong constitution, that must have been passed on to her by her family. Prescriptions for things to strengthen the constitution are thus explained, and, likely, appropriate, because the disease wasn’t curable anyway and ‘medicine’ at the time certainly wasn’t going to cure it! Sea-bathing was a popular one. Horseback riding was popular for hundreds of years–Thomas Sydenham popularized it in the 1600s (sound familiar?), with the dual benefit of exposure to the open air and ‘gentle stimulation of the constitution’. Anything that was stimulating but not over-taxing–swinging, which required little exertion, or sailing were often prescribed. Some rich folks took off on sailboats to Spain. Climate, too–led to examples like Dr. James Clark, who, in the early 1800s, moved to the south of France and eventually set up a clinic in Rome for English people looking to get healthy, and led to the whole sanatorium movement, where specific hospitals or retreats were made in warm climates to help people recover. This is a whole different episode, maybe TB part II, as the sanatorium movement helped grow the hospital movement, and was a look into class differences as well, since pauper ‘sanatoriums’ were quite different from those in the south of France. Fun shout out to Arizona, where Tucson was so popular as a sanatorium destination in the US during TB’s height that people ended up forming tent cities of TB patients outside the city once the multiple sanatoriums filled up. In addition to steps to improve the patient’s constitution, there were any number of direct therapies. There was a ‘consumptive diet’ which included large amounts of fat, which is called suet in the Victorian Era, usually from a specific animal because, as we all know, the best suet is mutton suet. Asses’s milk was very popular for some reason. They tried all sorts of medicines; arsenic and mercury were thankfully used less frequently than quinine–an alkaloid made from Cinchona trees against malaria still–and digitalis, or foxglove, which we’ve also covered. Both of these ‘helped’ by slowing the heart or ‘stopping’ fevers, but really not a great way to treat fever or tachycardia. So anyway that’s some of the medical background at the time, with this illness that is quite fascinating, and kills up to 80% of people that don’t clear it right away and accounts for a quarter, give or take, of deaths in London in the 1800s. The English, though, took this slow-moving epidemic and turned it inside out in a sort of mass cultural delusion which has a few points to discuss. First off, TB was romanticized to a tremendous degree. Emily Bronte was one example of how ‘dying of consumption’ was romanticized by the literary set, since she was the Amy Winehouse of books and only ever published one. Keats, one of the most famous so-called Romantic poets at the beginning of the eighteenth century died of TB. Keats wrote odes to melancholy and the transience of life. Byron, another famous poet and a contemporary of Keats, who wrote ‘she walks in beauty’, a famous pillar of English major life, noted at one point “How pale I look! – I should like, I think, to die of consumption … because then the women would all say, ‘see that poor Byron – how interesting he looks in dying!” Percy Shelly wrote to Keats at one point about this, and basically said, wow, looks like you still have TB, it sure likes us artistic types, doesn’t it? People took the idea that TB was related to constitution and applied it to standards of behavior and beauty in the upper classes; it was sort of assumed that it was a problem among the poor, which it was, but then, to the extent people died of TB among the upper classes, they would relate the infection to ways people were like the poor–linked to foul air, or living in the city when they could live in the country. Many if not all of these written opinions said women were more vulnerable than men because they were ‘indolent and inactive’. Physicians and others with opinions on TB linked lifestyle issues to TB with abandon, including the waltz when it became popular. As anatomists struggled to figure out what the nervous system did or how it worked, there was a whole concept of ‘sensibility’--like, an overactive nervous system–which was the cause of disease, and associated worry that a more refined life was leading to excitation of the nervous system, leading to a whole host of diseases, with TB among them. George Chyne, an English physician at the beginning of the Victorian Era, used this concept to turn health on its head and described what was called the ‘English Malady’--essentially, the price of England’s class, dominance, and wealth was a more excitable nervous system–that’s the sensibility–so that the very reason the English were so successful was the same reason they got sick. To some extent, if you were rich and sick, the sickness was a sign of how amazing you were. This extended to a whole host of maladies. In this setting, being sick with TB, previously romanticized and then linked to a sign of a superior nervous system, became fashionable. The fact that your pulse raced, you got pale and light-headed, and could barely deal with the slightest exertion, was in fact not malnutrition and low oxygen from advancing bacterial illness, but a sign that your nervous system was highly advanced, and actually proof of your high status. Fashion and beauty trends grew out of the above cultural underpinnings at the end of the nineteenth century, and the medical community happily took part. The London Medical and Surgical Journal in 1833, which basically said, in contrast to ‘uglier’ illness, ‘consumption, neither effacing the lines of personal beauty, nor damaging the intellectual functions, tends to exalt the moral habits, and exalt the amiable qualities of a patient’. Keep in mind, this is the description of a progressive bacterial illness that causes giant cheese-like lumps of dead white blood cells and bacteria throughout the body, leading to incessant coughing of blood and almost constant diarrhea until one dies of pneumonia. Fashion trends of the time focused on thinness and pallor as the beauty standards, which TB causes; corsets were used along with lots of other dress accessories to emphasize a slim waist, and make-up trends included rosy cheeks and pale skin. Projecting clavicles and wing-like scapulae were considered attractive, both of them a consequence of severe muscle wasting and what we call cachexia, which today can be seen in conditions that cause severe malnutrition. Writers were fully aware that TB was one of the causes emphasizing standards of beauty; one Victorian beauty essayist wrote that ‘in the last stage of consumption, a lady may exhibit the roses and lilies of youth and health, and be admired for her complexion the day she is to be buried’. It got to the point that medical texts would equate beauty with vulnerability to TB just as we consider high blood pressure a risk for heart disease today. Clothing trends throughout the 1800s were both pushed by this beauty standard and part of the debate over causation, because we all know clothing causes tuberculosis. Through the early 1800s, dresses exposed more skin, especially in the back, which was related to the scapula fashion, but was then attacked by many physicians as dangerous because we all know you catch cold when you go outside without suitable clothing. There’s so much discussion of wing-like shoulder blades in Victorian writing, either in favor or in disapproval. Women also stopped using flannel underwear which some physicians thought was quite dangerous. Lastly, corsets, which emphasized thin waists, were a huge point of debate, as they restricted both activity and, you know, breathing. I think it’s probably a great idea for the three of us to go on at length about fashion trends, right? There’s also a phenomenon called ‘tight-lacing’ which was prominent in use of corsets, by no means universal it looks like but common, that was condemned by many physicians as causative. Long trains on dresses were also blamed for kicking up dust that affected the lungs as women walked along dirt streets in London. This only intensified when Robert Koch isolated and identified the bacterium in the 1880s as the cause, at which point, other physicians said well the skirts must increase passage of the bacterium. I think it’s fair to say that men suffered equally from fashion trends when the voluminous beards of the late Victorian Era were largely attacked for the number of bacteria they held; Edwin Bowers, the doctor who pioneered reflexology, proved that even a blind squirrel finds a nut now and then when he said that ‘there is no way of knowing the number of bacteria and noxious germs that may lurk in the Amazonian jungles of a well-whiskered face, but their number must be legion’, blaming whiskers for tuberculosis, whooping cough, diphtheria, measles, and scarlet fever, to name a few. This led to a new clean-shaven fashion trend, especially among doctors, which is sad, because there are literally no beards like late nineteenth-century beards. Tuberculosis gradually declined in England for no good reason, really. It spread through the US as well a bit later, and, as I said, probably has fodder for another couple episodes with regards to the history it represents. Since I always like to end on an up note, just keep in mind that TB is deadlier than ever; most cases at this point occur in developing nations in Africa and Asia. There is a strong link to HIV, which potentiates infection. Because it’s so difficult to treat, we’re up to about 50 thousand cases a year of so-called XDR-TB, which is the X-games version of MDR-TB, or multi-drug resistant TB. The worst strains are resistant to multiple antibiotics, and are incredibly hard to treat. Our only good vaccine has a ton of real side effects and is only, right now, used in children and people with latent disease, I believe. Good times ahead with this still incredibly active disease. At least we can all die beautiful. References
Aaron Silver Fox Doc It’s National Osteopathic Medicine Week so what better time to dive into my own background. I, as a real, living, breathing Doctor of Osteopathy, will regale you with a history of my profession in medicine. This is something that has been a topic of particular interest to me and I’ve teased covering it for awhile. I will admit that I actually had no idea it was National Osteopathic Medicine Week and discovered that purely by coincidence while researching this show topic. That may show you how hardcore of an osteopath I really am. It’s fairly likely that many of our listeners may have been treated by a DO (doctor of osteopathy) at one point or another in their lives. My experience has been that patients usually don’t know I’m an osteopath until they squint at my badge and say the inevitable “What’s a DO?” line. It’s always vexing because I have to try and summarize the history of my wing of this profession in a soundbite while providing reassurance that I am, in fact, a real doctor and everything. I don’t imagine this happens to you guys. Though DOs are interchangeable with MD’s in all but title–you’ll find them doing family practice, internal medicine, and neurosurgery among all the other specialties–there is historic precedent behind the distinction of the title. DOs historically have wanted to maintain their DO-ness even as it’s been increasingly difficult to say what that distinctiveness is as we’ll find out. The DO difference all begins in response to a medical tragedy in 1864. A man named Andrew Taylor Still had lost his entire close family to meningitis. In that year his wife, three daughters, and one adopted child all succumbed to this bacterial infection of the brain. People respond in all sorts of unique and interesting ways after epic tragedies, and A.T. Still decided to re-think the principles of medicine as a result. This was at a time of bloodletting and leeches and “heroic medicine”. This was a time when doctors were supposed to do something and not “just stand there.” So they did things–ALL the things–to treat patients even when those things didn’t help. Bloodletting and leeches will not cure bacterial meningitis and A.T. Still was understandably frustrated by this. He thinks, “there must be a better way!” and the seeds of osteopathy were born. Let’s dive a bit into A.T. Still’s medical background. According to my research as well as my recollections from learning a bit of this history in medical school, A.T. Still did not have a formal medical degree so far as anyone can tell. In that time (again the 19th century), in the U.S. a person practicing medicine without a formal degree was not all that uncommon and was a problem we’ll talk about a bit later here. AT Still appears to have apprenticed to some degree under his father who was apparently a physician. After spending some time with his dad he entered into service in the Civil War with company F out of Missouri, on the side of the union. He was a hospital steward it would seem and would later describe himself as a “de facto” surgeon. In other words he was pretty much a surgeon by Civil War standards, just minus all the formal training and stuff so that should inspire confidence. Nevertheless it was not uncommon for hospital stewards in the Army to be promoted to roles like surgeon, especially given the awful circumstances in the medical encampments during that war. Stewards often functioned as pharmacists and all manner of general medical staff at that time. After the war is when his family dies and he begins to devote himself to medical complementary areas of study. Notably he was an avid anatomist and articles describe him as being a meticulous dissector person. Indeed, anatomy is emphasized as a foundation of osteopathic training because, as we’ll see, it’s at the root of many osteopathic principles of treatment. It should be noted that AT Still did seek out further medical education. He completed what was described as “a short course in medicine” at the then new College of Physicians and Surgeons in Kansas City, MO in 1870. I’d like to imagine this was a correspondence course or something to that effect. I’m not really sure how short the course was or what was covered, but I believe this is the last formal medical training he seemed to receive prior to founding osteopathy. In 1874, the very same year that had many exciting historical developments such as the 1st zoo opening in Philadelphia, Hary S. Parmalee patenting the sprinkler head, and the formation of the World Postal Union in Bern, Switzerland (finally, right?), A.T. Still “flung to the breeze the banner of Osteopathy.” I feel compelled to use those words which come from his autobiography partly because who can refuse such poetic grandiosity. I guess it sounds better than “I made up a new kind of medicine in response to a personal tragedy.” What is osteopathy exactly? Etymology nerds will note that the word means “bone pain/suffering,” more or less–osteo is bone, pathos is a bad thing. AT Still’s basic tenets of osteopathy included the following:
What this meant in the context of osteopathy as a new way to do medicine was the belief that the musculoskeletal system is the foundation of health and that proper functioning and diagnosis thereof is the key to treating disease. If the MSK system is out of wack, anatomically speaking, so too will other body systems malfunction–and vice versa, that if a problem arises within the intestines, one might find evidence of this is the MSK system and soft tissues. I’ll pause to let that wash over my MD colleagues here. Maybe I should add that AT Still, around the time of banner flinging, was really into spiritualism. Practically speaking, in the beginning, osteopathy was a purely manual manipulation type of practice. AT Still believed that an in-depth exam of the patient’s spine and other joints might give insight into whatever medical maladies they might have. Also, by manipulating the spine and other joints and soft tissues into a more normal alignment, one would improve the overall health of the patient. When the MSK and soft tissues are pathological or seemingly communicating an underlying pathology, this is referred to as “somatic dysfunction.” By the same stretch of the imagination, one could also do an exam of the MSK and soft tissues to find out what is happening with the internal organs. In the early days of osteopathy, this focus on manual medicine, so-to-speak, also meant traditional medications were eschewed. Granted, mercury containing calomel, arsenic, and the piles of opium that were typically prescribed around the end of the 19th century did not save people from things like bacterial meningitis, but I don’t think a good alignment of one’s spine and joints would either. Over time–extending into the present day–osteopathic manipulative medicine (OMM) evolved several general types of diagnosis and treatment. In osteopathic medical school, we as students had all of the normal medical school classes–anatomy, physiology, pharmacology, pathology, etc.--but in addition would have a 4-hour class every week in OMM principles and treatment, many of which derive from the writings and teachings of AT Still and his subsequent early osteopathic disciples. I won’t say that my views on the matter speak for all DOs, but when people ask me to describe what OMM is, I like to say it’s a spectrum of things that may have some semblance of physiologic plausibility to the embarrassingly pseudoscientific nonsense that should be called for what it is. Though manipulative medicine was once the only thing osteopaths did as medical intervention, we’ll see that over time this has come to be a very small part of DO practice in the modern day. On the possibly reasonable side of the spectrum would be “muscle energy” techniques. In the simplest sense this involves taking a joint to a position of restricted movement, having the person contract the muscles that move the joint against resistance, allowing a period of relaxation, and then stretching the joint to move further than it did beforehand. The process is repeated and the goal is to see increased movement and decreased discomfort in the area in question. Aside from the hokey name, this type of thing is performed by physical therapists as well as DOs. This is the one and only thing I ever use on myself, typically to get a good stretch before playing hockey. Towards the middle of the spectrum would be things like HVLA treatment. This is where a person is positioned in a variety of ways to try and take a spinal segment (though it can be used on other joints) into a position of restricted movement and a short thrust is made to move the segment a small distance at a quick pace. This often gets a little crack out of the joint and the underlying malady is cured. If this makes you think of a visit to the chiropractor’s office you’re not far off as there is a lot of overlap in what osteopathic and chiropractic techniques seem to look like. This is perhaps because D.D. Palmer, the so-called father of chiropractic medicine, wrote about taking a course in osteopathic medicine in 1899 so I can’t help but think these two bits are related. There will be many in the DO world that might take issue with that, but I would say it’s my opinion that there is not much sunlight between HVLA treatment and chiropractic treatment. In practice DO’s, including myself of course, are taught a system of pressing on the spine and surrounding soft tissues to see if a vertebral segment seemed to be rotated oddly or bent strangely and try to put it back into its proper place. I put this in the middle of my spectrum of plausibility because there is at least some research to suggest OMM may help with specific low back pain patients. At the far end of the insanity spectrum is cranial osteopathy. This was where I, and many of my DO med school friends had a career choice existential crisis. I recall sitting in a vast lecture hall–the same one that held amazing lectures on neuroanatomy, microbiology, and pathology–and being presented with the principles of cranial osteopathy. Developed in the 1930s by Dr. William Garner Sutherland (DO of course), the tenets of cranial osteopathy hold that contrary to all known anatomical knowledge, the bones of the skull which fuse together in early childhood, around the age of two, are actually capable of movement. There is the belief that there is an underlying Cranial Rhythmic Impulse that can be felt 8-14 times per minute as the cerebrospinal fluid surrounding the brain pulses to and fro. By feeling the amplitude and rate of this CRI, one skilled in cranial osteopathy can diagnose underlying pathology or try to treat it by restoring the pulse to normal. I was sitting in class while this was being described and I, as a staunch skeptic then and to this day, was horrified. It will not surprise you to find out that despite many, many, many efforts to prove the concept, the CRI has not been demonstrated to exist and skull bones do not move to any perceptible degree. Many prominent DOs have spoken out or written about the need for osteopathy to stop teaching this. I share that opinion as you might imagine because this is absolutely bunk and does not belong in a medical school curriculum outside of mention as a historical part of the profession that was, medically speaking, complete nonsense. Myself and several friends and colleagues actually refused to participate in practice of this during our OMM classes towards the end of medical school. With those principles in mind, we’ll return to the story of how DOs gradually became respected members of the medical profession. From the founding of the American School of Osteopathy in Kirksville, MO by AT Still himself in 1892 until the 1950’s or so, DO medical practice was purely OMM treatments. DO schools did not start teaching the principles of pharmacology at all until 1929, over ten years after the death of A.T. Still in 1917. I’m not sure he would have liked that. In the early 20th century, however, DOs started to adopt more and more principles of traditional MD medical training and the profession moved to legitimize itself in the house of medicine. This was a long, uphill battle for the better part of the last 100 years. The first test was, fittingly, passed by the DO schools themselves. I mentioned the problem of the whole “how to be a doctor” thing being too unregulated earlier. This was a major problem in the US in the early 20th century. To codify and improve medical education, something called the Flexner report was released and it called for a systematic way to vet and credential medical schools and the education of physicians in general. Though the DO schools of the time did not teach a curriculum identical to their MD counterparts, they did have rigorous study of anatomy and physiology and, with some adjustments, were able to survive the fallout from the Flexner report. To put it into perspective, there were 155 medical schools in the US in 1910 at the time of the report’s release. After the report, 31 schools remained standing and able to graduate doctors. Many of the early DO schools were among them and are still in operation to this day. This was a big step towards legitimizing DOs in medicine. In the 1950’s, osteopathic practice started to incorporate more concepts of what we’d call primary care. Many DOs went into family practice while still doing manipulative medicine. Though pharmacology was regularly taught in DO schools for the prior 20 years, there were some interesting growing pains. While I was in medical school, one of my neighbors was a long-retired DO who graduated in 1955. He took my wife and I out to dinner once and told us a bunch of amazing stories, including the fact that in the 50’s, where he practiced, he would have to contract with an MD to sign his prescriptions to make them official. Different times to be sure. It was in the 1940’s and 1950’s that DOs found themselves butting heads with MDs and the American Medical Association in general. As recently as 1961, the AMA code of ethics had declared it “unethical for a medical physician to voluntarily associate with an osteopath”. Prominent MDs in the AMA wrote about DOs in rather unflattering terms. In 1954, osteopathy was described as “cultish” in a paper by Dr. Charles L. Farrell, M.D. who opposed cooperation between MDs and DOs. He, and many others, pointed to what they deemed to be pseudoscientific practices within OMM and what appeared to be staunch adherence to A.T. Still’s principles of medicine despite evidence to the contrary. Farrell’s objections included a citing from a 1952 osteopathic textbook which stated “A.T. Still’s discoveries have been ‘progressively confirmed’ and ‘never invalidated.’ To that effect I can empathize with where these MDs were coming from in this regard. From 1916 to 1966 osteopaths were in a “long and tortuous struggle” to serve as physicians and surgeons in the military as one article put it. DOs were not allowed to have practice rights in the US military during WWI and WWII. This changed when on May 3rd, 1966, Secretary of Defense Rob McNamara authorized DOs to be accepted into all military branches on equal practice basis as MDs. This was a big step for the DO profession. As DOs were practicing more traditional medicine, what with all the pharmacology and stuff, there were a few more hiccups with the AMA in the 1960’s. A notable example took place in California in the 1960’s where not much else was going on, historically speaking. The AMA, at that time, spent $8 million dollars to stop osteopathy in the state. Proposition 22, a statewide ballot initiative, barred DOs from practicing in California. The California Medical Association offered to issue DOs an MD degree if they payed a $65 fee and took a “short seminar” to bestow them with MD-ness, I guess. 86% of the DOs at the time in California took them up on the offer. I don’t know how much of that was due to needing it to practice medicine at all in CA at the time, or how much was a rebuke to keeping the DO degree and identity separate. The AMA re-accredited the University of California at Irvine College of Osteopathic Medicine as University of California, Irvine School of Medicine (MD School) and banned the issuing of MD licenses to DOs moving to Cali from out of state. This all stood until 1974 when protests and lobbying of the California supreme court by prominent DOs allowed osteopathic licensing to resume in the state. As an aside, the DO degree was not uniformly recognized in all US states until 1973. By 1969, the professional rift between DOs and MDs starts to mend. That year, it was approved that DOs can be part of the AMA and DOs were also allowed to participate in MD residencies–not allowed before this. Interestingly, the American Osteopathic Association (our AMA, if you will) rejected the measure to let DOs go to MD residencies. There were efforts then, and some still now, to keep the DO degree and approach to medicine as a whole, as a separate and distinct identity. At the time I attended and graduated from residency, I had to make a choice whether to apply to DO residiencies or MD residiencies, opting for the latter. I had to take two sets of boards (MD vs DO boards are different) and many of my compatriots had to make similar choices. In 2014, however, the AMA and AOA merged the residency process removing the distinction. I see this as a very good thing, personally. With that gradual evolution, the DOs of today are interchangeable with MDs in all other aspects. Several of my classmates are in all the fields and hypersubspecialties of medicine. This has led to an interesting question of what, in the modern era, makes the DO degree and DO physicians all that different. According to a study from the Journal of Osteopathic Medicine done in 2021, the data suggests the use of osteopathic manipulative medicine in practice is declining. This was definitely the case when I was in school, too. Of 10,000 surveyed DOs in that study, only 16% responded and of those, ¾’s of themused OMM on less than 5% of their patients and just over half did not use OMM at all. So if DOs are not practicing OMM much at all in the real world, what is the distinction of the DO profession at this point. Why have a separate degree at all? I do have strong opinions on the matter but this is a history show so I’ll spare them–I suspect many listeners might guess what I think. I should also mention that osteopathy and the practice thereof as a medical provider may look very different in other countries. While D.O.’s may have full practice and prescribing rights in the U.S., Canada, and many, many other countries, some countries do not allow DO’s to practice in such ways–France as an example. In this regard, DOs can only practice manipulative medicine and not prescribe. My final thought, and the reason I wanted to do a show on the history of my own degree, is to leave you all out there with a positive impression. The historical origins of the degree are certainly interesting and worth remembering, but many of the pseudoscientific concepts that may have been taught–or might still be taught–in the world of OMM are far from defining features of osteopathic training. DOs are in every area of medicine doing incredible work. DOs have been surgeon generals and are every bit as capable as our MD colleagues. So if you notice your doctor is a DO on your next visit, perhaps you’ll know a little more about why initials following their name are just a bit different. In the end, a good doctor is a good doctor. Sources: https://books.google.com/books?id=H08EAAAAMBAJ&q=andrew+taylor+still+lightning+bone+setter&pg=PA108#v=snippet&q=andrew%20taylor%20still%20lightning%20bone%20setter&f=false (Life article about AT Still) https://quackwatch.org/chiropractic/rb/bcc/8-2/ (Farrell comments on osteopathy) https://pubmed.ncbi.nlm.nih.gov/22331804/ (DOs not able to serve in WWI and WWII as docs). https://en.wikipedia.org/wiki/Osteopathic_medicine_in_the_United_States#History (General overview) https://en.wikipedia.org/wiki/Andrew_Taylor_Still (AT Still’s life overview) https://www.amboss.com/us/knowledge/Cranial_osteopathy/ (Cranial stuff) https://bmjopen.bmj.com/content/12/4/e053468 (Summary of research on OMT) https://pubmed.ncbi.nlm.nih.gov/33512391/ (OMT use in US nowadays) https://www.aacom.org/become-a-doctor/about-osteopathic-medicine/history-of-ome (timeline of notable DO historical events) Max Doctor with a mustache. |
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